Provider Demographics
NPI:1437140084
Name:PALMYRA PROFESSIONAL FEES LLC
Entity Type:Organization
Organization Name:PALMYRA PROFESSIONAL FEES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP (INTERIM)
Authorized Official - Prefix:MR
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-661-3365
Mailing Address - Street 1:2000 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1528
Mailing Address - Country:US
Mailing Address - Phone:229-434-2161
Mailing Address - Fax:229-434-2502
Practice Address - Street 1:2000 PALMYRA RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1528
Practice Address - Country:US
Practice Address - Phone:229-434-2161
Practice Address - Fax:229-434-2502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD1828OtherRR MEDICARE
DD1828OtherRR MEDICARE
GAGRP6388Medicare ID - Type Unspecified